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CONTACT INFORMATION
First Name
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Condition
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Bladder Cancer
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Benign Prostatic Hyperplasia (BPH) or Enlarged Prostate
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Overactive Bladder (OAB)
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Overactive Bladder
Have you received a diagnosis of Overactive Bladder (OAB) from a provider?
*
Yes
No
Have you ever taken a medication to treat your Overactive Bladder symptoms?
*
Yes
No
Have you tried any other treatments for your Overactive Bladder? If so, please list them here:
Do you have any other medical conditions that we should be aware of? Please list here or write 'none'.
Would you like to be contacted about taking part in a clinical trial for Overactive Bladder (OAB)?
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Yes
No
If you do not qualify for our current Overactive Bladder Trials, would you like to schedule an appointment to see a physician for your symptoms?
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Yes
No
If you do not qualify, is it ok for us to add your name to a list for possible future studies?
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Yes
No
How did you hear about us?
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Disclaimer
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I understand all clinical trials are completed in Omaha, Nebraska.
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